By Sharon Tregaskis

TNancy Speck was initiated into the sisterhood of breast-cancer survivors five years ago, when a colleague took the professor of biochemistry to lunch, answered the questions a doctor can't, and even showed Speck her own post-mastectomy reconstruction. "I could live with that," Speck remembers thinking. So she called to make an appointment with Dartmouth plastic surgeon Dale Collins, M.D., director of the Comprehensive Breast Program at DHMC's Norris Cotton Cancer Center.

Now Speck often finds herself returning the favor bestowed by that colleague—sharing her own story and showing women grappling with treatment options how her body fared. "People tell me, 'That's the nicest reconstruction I've ever seen,' " says Speck, who never fails to give Collins credit for the work. Even her primary-care practitioner was impressed, Speck adds. She has since served on DMS committees with Collins and now counts the plastic surgeon as a close friend. "One of the things I like most about her is her perfectionism," says Speck. "She does a really beautiful job."

It wasn't long after Collins arrived in Hanover in 1995 that she expanded her hand and microsurgery practice and began to offer breast reconstruction. Two early breast-cancer patients alerted Collins to an issue that has since become the focus of her career: providing patients with clear, objective information about their treatment options and supporting their autonomy as they pursue their own best interests. Those two patients "both elected [to have]mastectomies, and both felt upset that they had disappointed their [oncological] surgeon," Collins recalls. "It was distressing to me that they were made to feel judged for their decisions. They were informed, understood the issues, and elected mastectomy." The sad part, adds Collins, is that the surgeon who treated them probably didn't realize that he had so clearly telegraphed his disappointment when both women decided not to follow his recommendation to have a lumpectomy and radiation.

That insight sparked Collins's quest to develop bias-free methods to help patients understand both their diagnoses and the full range of treatment options open to them. It's a quest that led her to complete Dartmouth's master'sdegree program in the evaluative clinical sciences, so she could learn more about shared decision- making. And it's what guides her ongoing work with DHMC's Comprehensive Breast Program (CBP).

Today, the associate professor of surgery heads a $3.5-million multispecialty investigation of shared decision-making, serves on the DHMC Board of Governors, and chairs the American Society of Plastic Surgeons' Committee on Performance Metrics. Last year, the Institute forWomen's Health and Leadership at Drexel University's College of Medicine named Collins a Hedwig van Amerigen Executive Leadership in Academic Medicine Fellow—an honor that is accompanied by an intensive training program aimed at grooming women faculty for institutional leadership roles.

"Dale is one of the smartest and most accomplished people I know," says University of Michigan plastic surgeon Amy Alderman, M.D. "She has excelled in a male-dominated specialty, but she's very much kept her femininity. To me, Dale is the perfect female leader in that she has excelled because she's really smart and very hardworking and has just enormous amounts of integrity. She hasn't changed who she is to try to succeed."

Most of the nation's comprehensive breast-cancer programs are headed by oncologists. As far as she knows, Collins is the only plastic surgeon in such a role. A comprehensive program is one in which the patient has a single point of contact for every part of her treatment—from diagnosis to surgery to reconstruction or radiation. Oncologists, social workers, nutritionists, radiologists, pathologists, nurses, and plastic surgeons all coordinate their schedules behind the scenes for the convenience (and peace of mind) of the patient, rather than the patient needing to make multiple phone calls to coordinate her own care.

Since her 1999 appointment as themedical director of Dartmouth's CBP, Collins has been relentless in implementing, investigating, and evaluating shared decision-making—an approach to treatment that incorporates the vantage points of all those specialists, as well as the patient's own preferences and values. Inevitably, conflict emerges as those perspectives collide.

"My goal is to make sure that we have the conversations and at least hear each other's perspectives and review the data," says Collins, who feels her training as a plastic surgeon—with its emphasis on patient satisfaction and quality of life—helps when communicating with colleagues in other fields.

"What one specialty preaches isn't necessarily what another specialty practices," she points out. "You have to be willing to step back and examine the evidence across the board and not just from a specialty perspective."

Collins has also made it a priority to balance the CBP's emphasis on patient-centered care with a commitment to creating a work culture that supports the whole team providing that care: from physicians and other health-care professionals to the administrative staff who coordinate the effort. "The nature of the program is to ease the patient's journey through treatment by having a single phone number to call and having care coordinators available to help the patient through it," explains shared decision-making project coordinator Caroline Moore, who began working with Collins in 2001. "From the perspective of the administrators who answer that phone, they're doing a ton of coordinating behind the scenes [to] make it all seemseamless for the patient."

To ease the strain on those staff members, and foster relationships that can enhance collaboration, Collins instituted an informalmonthly luncheon to honor administrative assistants throughout the program—people who might otherwise never interact face-to-face. The effort has been a huge success, says Moore, opening doors and creating a sense of teamwork.When there's conflict, Collins assumes that the person causing it is under stress. "If we can figure out what's behind the stress, we can usually work [the conflict] out," says Moore. "She really believes in the goodness of everyone."

Collins is a tough taskmaster when it comes to herself, however. Eliminating her own bias in patient counseling, for example, hasn't been easy. "I found it really hard to do," she admits. "You believe what you believe, and even when you try really hard to be factual, you choose information that reflects your bias." The difficulty should be no surprise, she admits—it's a physician's job to consider the facts in each patient's case, integrate them with what you know based on your past experience and training, and then counsel that patient accordingly.

Ultimately, the effort requires balancing the objective and subjective particulars of a patient's situation against objective data about the pros and cons of a full range of treatment options and the specialist's expert intuition. Collins seems to have a knack for it, says Nancy Speck, who grappled with whether to have radiation following a lumpectomy, or reconstruction following a mastectomy, in her own fight against breast cancer. "[Dale] was very helpful in helping me think through the decision," says the biochemist, "presenting the risk factors for recurrent cancer and how that might or might not be averted with mastectomy."

In 2002, Collins began experimenting with urging newly diagnosed breast-cancer patients to watch a neutral video on treatment options before she presented her recommendations. An information technology aficionado (she serves on the steering committee for DHMC's Information Survey Systems), she had developed an electronic survey to evaluate the concept. She invited her colleagues in the CBP to test the video approach and survey.

But given their jam-packed schedules, and their gut instinct that they were already providing patients with objective recommendations, some of the doctors weren't enthusiastic about testing something new. To counter their skepticism, Collins incorporated questions on the survey to elicit information that she knew her colleagues would find useful—such as any points of confusion a patient had about her diagnosis and the patient's individual treatment preferences—and began generating a patient-specific report before each appointment.

In the end, Collins got her colleagues hooked on the new system, while simultaneously generating vast amounts of valuable patient data. "Dale is a master at demonstrating the value of an initiative by wrapping things into it that can benefit the providers," saysMoore. "It was all linked with her goal to provide the patient with decision support."

Ironically, it wasn't until she was well along in hermedical education at Emory that surgery even made it onto Collins's list of career prospects. In fact, she originally enrolled there as a Ph.D. student in the neuropharmacology program. "I was very problem-focused," says Collins, and "love puzzles, finding solutions." But the program lacked any clinical application or relevance so, after a year, she transferred to Emory's medical school. There, she discovered a fascination with dissections. "I kept saying, 'This is really interesting,' she recalls. " 'It's too bad I wouldn't want to be a surgeon.' " But when she did her first rotation—in surgery—she happened to be assigned a terrific mentor and her perspective began shifting.

Today, Collins makes a point of returning the favor granted by that long-ago surgeon. She provides counsel and mentorship to the whole range of individuals with whom she works—from administrative assistants seeking out new professional opportunities, to undergraduates and medical students looking for research opportunities, to residents or colleagues searching for clarity in their careers. Among CBP staffers, says Moore, that attitude has engendered passionate loyalty and low turnover. "With Dale, you never feel like there's a totem pole," says Moore, who started out with the program as a part-time secretary. "She's very team-oriented, makes everyone feel valued, and pushes everyone to develop their own goals and careers."

Back in 2001, Amy Alderman was a resident in plastic surgery at Michigan who wasn't quite sure what career path to take. Her division chief recommended that she spend a week at Dartmouth observing Collins, who was already nationally recognized in the field. Alderman took the advice and now counts Collins among those who've had the most influence on her career over the past six years. "Dale is the kind of person who tries to make other people look great," says Alderman. "She's a very giving person and really tries to help people. . . . There aren't many Dales in the world."